Population Health Management

Four Strategies to Maximize Adult Immunization Quality and Financial Benefits

March 10, 2017 10:36 am

Although the future of healthcare legislation is uncertain, experts agree that value-based care is likely here to stay. Commercial health plans and the Centers for Medicare & Medicaid Services (CMS) are expected to continue their goals to replace volume with value as key criteria for payment. That means providers should remain vigilant about the collection and analysis of quality metrics.

Some quality measures, such as maintaining healthy hemoglobin A1c levels in patients with diabetes, are especially challenging because they require ongoing attention. Immunizations, on the other hand, offer healthcare organizations more straightforward opportunities for improved care quality and payment. Most don’t require complex data collection or long-term monitoring.

Pneumococcal screening and immunization for senior adults is one high-profile quality metric to consider: it relates to CMS accountable care organization measure 15, National Quality Forum (NQF) measure 0043(which is also a measure for CMS’s Merit-Based Incentive Program) and an NCQA Healthcare Effectiveness Data and Information Set (HEDIS®) measure.

Even better, pneumococcal immunizations PCV13 and PPSV23 are “one and done” immunizations that don’t require multiple administrations for most older adults. They are a good example of a way organizations that identify the most manageable quality metrics stand to reap greater payment benefits faster—not to mention improved patient outcomes.

Immunization claims do pose a few hurdles, but those hurdles are quite manageable with the right guidance and procedures in place. Here are some strategies to overcome four common challenges in professional billing.


Clinicians must know the mandated intervals between immunizations. For example, senior adults receiving pneumococcal immunizations should wait a year between receipt of PCV13 and PPSV23. If a patient receives PCV13 at some place other than his or her primary care practice—at a pharmacy, for instance—and the primary care practice has no record of the immunization, it risks being denied payment for administering PPSV23 too early.

Creating alerts in the electronic health record (EHR) system can prompt staff and clinicians to ask patients about recent immunizations. State, local, and regional immunization registries also are a growing source of adult immunization data; they are not just for childhood immunizations. Easily accessible resources can help a practice establish the right immunization timeframes; for instance, the Centers for Disease Control and Prevention (CDC)shares regularly updated immunization schedules via its website and the Morbidity and Mortality Weekly Report.

Procedure Codes

The American Medical Association provides Current Procedural Terminology (CPT®) codes for billing immunizations, and CMS provides additional Healthcare Common Procedure Coding System (HCPCS) codes for services that have no CPT code. The CDC also posts a comprehensive list of immunization CPT codes online, with crosswalks to other code types. However, it’s also important to know the specific guidelines set forth by health plans for billing immunizations. Otherwise, staff can make small but significant errors that prompt denials. Revenue cycle staff should proactively seek payer-specific information. Most health plans publish a billing manual with these data. Staff should also review each health plan’s denials to identify any trends.

Diagnosis Codes

Revenue cycle staff must link the correct diagnosis code to the immunization procedure code in order to avoid claim rejections. One good practice is to leverage ICD-10 coding reference tools, such as the Medicare Learning Network, to understand CMS’s immunization coding requirements. The National Adult and Influenza Immunization Summit (NAIIS) is collecting immunization coding and billing resources and tips to post on a new NAIIS web page, which is coming soon. Organizations such as the Immunization Action Coalition provide additional resources.


Denials can result when health plan policies indicate an immunization should be billed as part of another service (such as an office visit) but staff improperly bill it separately. That’s called “unbundling.” The key is to understand when services are bundled and when the guidelines allow separate payment. Typically, a health plan will not pay for any service billed separately from an immunization that it has not deemed to be significant and separately identifiable.

Claim scrubber software and other billing tools can help identify unbundling errors before they result in denials. CMS also provides free downloadable files to show what can be unbundled.

Health care is shifting from reactive to proactive care. Immunizations fit right in by helping prevent serious disease. In an era when quality metrics are increasingly critical and reimbursements are harder to realize, leveraging immunizations as a step toward proactive care and greater claims revenue can make all the difference.

Jill Powelson, MBA, MPH, RN, CPC, is director of clinical translation at AMGA, Alexandria, Va. 


googletag.cmd.push( function () { googletag.display( 'hfma-gpt-text1' ); } );
googletag.cmd.push( function () { googletag.display( 'hfma-gpt-text2' ); } );
googletag.cmd.push( function () { googletag.display( 'hfma-gpt-text3' ); } );
googletag.cmd.push( function () { googletag.display( 'hfma-gpt-text4' ); } );
googletag.cmd.push( function () { googletag.display( 'hfma-gpt-text5' ); } );
googletag.cmd.push( function () { googletag.display( 'hfma-gpt-text6' ); } );
googletag.cmd.push( function () { googletag.display( 'hfma-gpt-text7' ); } );
googletag.cmd.push( function () { googletag.display( 'hfma-gpt-leaderboard' ); } );